<wicket:panel>
	<form method="post" action="https://onedev.io/support-request" class="support-request leave-confirm">
		<div class="modal-header">
			<h5 class="modal-title">Submit Support Request</h5>
			<button wicket:id="close" type="button" class="close"><wicket:svg href="times" class="icon"/></button>
		</div>
		<div class="modal-body">
			<div class="form-group">
				<label class="control-label">
					<span class="mr-1">Contact Email</span> <span class="text-danger">*</span>
				</label>
				<input wicket:id="contactEmail" type="text" class="form-control contact-email" name="contactEmail">
				<div class="text-danger mt-1 error-message">Must not be empty</div>
			</div>
			<div class="form-group">
				<label class="control-label">
					<span class="mr-1">Contact Name</span><span class="text-danger">*</span>
				</label>
				<input wicket:id="contactName" type="text" class="form-control contact-name" name="contactName">
				<div class="text-danger mt-1 error-message">Must not be empty</div>
			</div>
			<div class="form-group">
				<label class="control-label">
					<span class="mr-1">Summary</span><span class="text-danger">*</span>
				</label>
				<input type="text" class="form-control summary" name="summary">
				<div class="text-danger mt-1 error-message">Must not be empty</div>
			</div>
			<div class="form-group">
				<label class="control-label">
					<span>Description</span>
				</label>
				<textarea type="text" rows="10" class="form-control description" name="description"></textarea>
			</div>
			<input wicket:id="siteInfo" type="hidden" name="siteInfo">
			
			<div class="mt-4">
				<button type="button" class="btn btn-primary submit mr-1">
					Submit
				</button>
				<button wicket:id="cancel" class="btn btn-secondary">Cancel</button>
			</div>
			<div class="site-info mt-5">
				<div class="alert alert-notice alert-light mb-4">Below information will also be sent</div>
				<div class="title mb-2">Basic Info</div>
				<table class="mb-4">
					<thead>
						<tr>
							<th>Product Version</th>
							<th>Agent Count</th>
							<th>License User Count</th>
							<th wicket:id="remainingUserMonthsOrTrialExpirationDateLabel"></th>
						</tr>
					</thead>
					<tbody>
						<tr>
							<td wicket:id="productVersion"></td>
							<td wicket:id="agentCount"></td>
							<td wicket:id="licenseUserCount"></td>
							<td wicket:id="remainingUserMonthsOrTrialExpirationDate"></td>
						</tr>
					</tbody>
				</table>
				<div wicket:id="serversAndSubscriptionKeys"></div>
			</div>
		</div>
	</form>
</wicket:panel>